The Economic Value of Treating Pediatric Obesity: Costs Are Not Keeping Up With Efficacy
Authors: Justin R. Ryder, Francesca Lim, Chin Hur
Journal: JAMA Network Open (2023)

Obesity is the most common chronic disease in the pediatric population, impacting approximately 15 million children and adolescents. 1Clinical practice guidelines from the American Academy of Pediatrics indicate that intensive treatment should be offered to youth with obesity, especially those older than 12 years, irrespective of comorbid conditions. 2 While lifestyle modification remains the cornerstone of treatment, biology-based treatments with antiobesity medications (AOMs), as well as metabolic and bariatric surgery, have shown tremendous success over the past several years in terms of weight loss efficacy.[5] The study by Mital and Nguyen 6 asked the simple, although potentially premature, question of whether AOMs are cost-effective for adolescents.Their findings, not surprisingly, are "not really." 6t a reasonable willingness-to-pay threshold of $100 000 to $150 000 per quality-adjusted life-year, only the combination of phentermine and topiramate was found to be cost-effective in several potential scenarios.Semaglutide was deemed to be the most effective medication leading to the greatest gain in quality-adjusted life-years, but its high cost prohibited it from being a cost-effective treatment option. 6Mital and Nguyen 6 analyzed all current AOMs approved by the Food and Drug Administration for adolescents and included metformin, sleeve gastrectomy, and gastric bypass in scenario analyses to create a comprehensive picture of all pharmacological and surgical treatment options available to adolescents.However, with the inclusion of metformin, AOMs were not found to be cost-effective.Interestingly, while previous studies have highlighted the cost-effectiveness of adolescent bariatric surgery, 7 the modeling conducted by Mital and Nguyen 6 found that surgery is not costeffective compared with phentermine and topiramate.Caution is warranted when a modeling analysis includes competing strategies for which the clinical end points used in model construction are from disparate patient populations.Such is the case in the model used by Mital and Nguyen, 6 as the bariatric surgery data used in sensitivity analyses were obtained from older adolescent patients with a higher baseline body mass index and with a higher proportion of comorbid conditions compared with the modeled patient cohort using AOMs. 8,9Moreover, longer-term data are available for adolescent bariatric surgery (Ն5 years), compared with only 1 year of data for all AOMs.This makes comparisons between treatment options very challenging due to the need to extrapolate outcomes from AOMs beyond 1 year.Furthermore, a true head-to-head comparison of bariatric surgery and AOMs is needed to reduce bias that might influence differences in outcomes, namely selection bias of those who are willing and eligible for such trials.The cost-effectiveness results presented by Mital and Nguyen 6 were generally robust to changes in model parameters, including body mass index progression, treatment discontinuation, and drug efficacy, with phentermine and topiramate continuing to be the cost-effective option.However, these results must be considered in context of several limitations.Due to lack of long-term data, it is unclear whether weight reduction would be maintained beyond 1 year of treatment and how much weight regain would occur when treatment is discontinued.It is also unknown whether adolescent patients would continue to use AOMs into and throughout adulthood, despite obesity being a chronic disease that requires long-term treatment.Mital and Nguyen 6 performed several